Provider Demographics
NPI:1659936995
Name:LARSON, RYAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 BRIDGEWOOD DR
Mailing Address - Street 2:STE 106
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112
Mailing Address - Country:US
Mailing Address - Phone:855-339-6978
Mailing Address - Fax:855-329-6978
Practice Address - Street 1:1100 BRIDGEWOOD DR
Practice Address - Street 2:STE 106
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112
Practice Address - Country:US
Practice Address - Phone:855-339-6978
Practice Address - Fax:855-329-6978
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1295247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist